Provider Demographics
NPI:1447642889
Name:GENDREAU, ROBERT JR
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:GENDREAU
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2141
Mailing Address - Country:US
Mailing Address - Phone:415-515-9734
Mailing Address - Fax:
Practice Address - Street 1:173 OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-2141
Practice Address - Country:US
Practice Address - Phone:415-515-9734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000626171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist